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case records of the massachusetts general hospital


Founded by Richard C. Cabot
Nancy Lee Harris, m.d., Editor
Eric S. Rosenberg, m.d., Associate Editor
Jo-Anne O. Shepard, m.d., Associate Editor
Alice M. Cort, m.d., Associate Editor
Sally H. Ebeling, Assistant Editor
Christine C. Peters, Assistant Editor

Case 21-2008: An 11-Month-Old Boy


with Fever and Pulmonary Infiltrates
Jason B. Harris, M.D., Ian C. Michelow, M.D., Sjirk J. Westra, M.D.,
and Richard L. Kradin, M.D.

Pr e sen tat ion of C a se


From the Departments of Pediatrics
Pediatric Infectious Disease (J.B.H.,
I.C.M.), Radiology (S.J.W.), and Pathology
(R.L.K.), Massachusetts General Hospital; and the Departments of Pediatrics
(J.B.H., I.C.M.), Radiology (S.J.W.), and
Pathology (R.L.K.), Harvard Medical
School.
N Engl J Med 2008;359:178-87.
Copyright 2008 Massachusetts Medical Society.

178

An 11-month-old boy was admitted to this hospital because of fevers and pulmonary infiltrates. One month before admission, a month after beginning a visit to
India with his parents, daily fevers, with temperatures up to 38.9C, developed, without localizing signs or symptoms. Before the family left for India, the boys primary
care physician gave him one dose of immunoglobulin intramuscularly for hepatitis
A prophylaxis and prescribed mefloquine weekly for malaria prophylaxis. He was
evaluated at an Indian health care facility, and amoxicillinclavulanate was administered, but there was no improvement. On the sixth day after the onset of fevers,
mefloquine was stopped and chloroquine was administered for 3 days, followed by
ciprofloxacin for 3 days. Fever persisted, and a nonproductive cough developed.
Nineteen days before his admission to this hospital, the patient was admitted
to a hospital in India. His blood pressure was 90/60 mm Hg and his pulse 138 beats
per minute; although he had been febrile, his temperature was normal. Hepato
splenomegaly was noted, but the results of the remainder of the examination were
normal. Laboratory-test results are shown in Table 1. No parasites were seen on
examination of a peripheral-blood smear, and a test for serum antibodies to Salmonella typhi was negative. A chest radiograph showed an irregular perihilar parenchymal opacity with air bronchograms and multiple smaller air-space opacities in
the left perihilar region. Ampicillinsulbactam and amikacin were administered
intravenously. A tuberculin skin test showed no induration after 48 hours, and the
temperature, which had been fluctuating, returned to normal on the fifth hospital
day. Intravenous fluid being infused through a catheter inserted in the dorsum of
the right distal forearm infiltrated into the tissue, and an adhesive bandage was
applied over the site. The patient was discharged on the sixth hospital day, receiving oral amoxicillinclavulanate and clarithromycin, and his cough gradually resolved. Nine days after discharge, and 5 days before admission to this hospital, he
returned to the United States.
Two days after his return to the United States, his temperature rose to 39C,
and fever recurred daily thereafter. The amoxicillinclavulanate was stopped after
completion of the course of therapy; the day before admission to this hospital, the
clarithromycin was completed. On the day of admission, he was evaluated at the
office of his primary care physician; his temperature was 38.7C. An erythematous
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Table 1. Results of Laboratory Tests.


Reference Range
(Age-Adjusted)

Variable
Hematocrit (%)

33.039.0

Hemoglobin (g/dl)

10.513.5

White cells (per mm

3)

6.0x10317.5x103

20 Days before
Admission
in India*

Current
Admission

11.0

4th Hospital Day

6th Hospital Day

33.7

33.8

26.8

11.5

11.1

8.9

32,800

28,900

36,400

24,700

Differential count (%)


Neutrophils

1749

42

37

39

45

Lymphocytes

6777

56

61

47

31

Monocytes

411

Eosinophils

08

Basophils

03

Band forms

010

12

Atypical lymphocytes

Platelets (per mm

3)

Mean corpuscular volume (m3)

150,000450,000

396,000

465,000

319,000

66

67

67

7086

Red-cell morphology

3+ microcytes

Erythrocyte sedimentation rate


(mm/hr)

017

C-reactive protein (mg/liter)

<15

75

3+ microcytes, 1+
hypochromia

3+ microcytes, 2+
hypochromia,
rouleaux formation present

59
143.8

Immunoglobulin (mg/dl)
IgG

2831026

815

IgA

1682

61

IgM

39141

60

* Reference ranges for laboratory testing performed in India include hemoglobin 13 to 18 g per deciliter, white cells 4000 to 10,000 per cubic
millimeter, neutrophils 40 to 75%, lymphocytes 20 to 45%, and eosinophils 1 to 6%.

nodule, 15 to 18 mm in diameter, was present on


the dorsum of the right distal forearm, at the site
of the previous venipuncture. There were no
other localizing signs or symptoms. A chest radiograph showed bilateral pulmonary infiltrates.
A biopsy of the nodule on the forearm was performed, and specimens were sent for culture and
pathological examination. The patient was referred to this hospital for admission.
The patient was born in the United States after
a full-term gestation to a primigravid mother; delivery was by cesarean section because of cephalopelvic disproportion. At birth, the patients
weight was 3.075 kg (21st percentile) and his
length 53.3 cm (90th percentile). At 6 weeks of
age, he had been admitted to another hospital for
a self-limited episode of fever and poor feeding.
A palpable spleen tip was noted on examination,
and ultrasonography of the abdomen revealed

that the spleen was 6.2 cm in length, the upper


limit of normal for his age. A culture of the
blood was sterile; his temperature returned to
normal and he was discharged. Follow-up ultrasonography of the abdomen 1 month after discharge was normal. Routine immunizations were
given, and developmental milestones and growth
parameters were normal. At 6 months of age, his
weight was 7.1 kg (18th percentile) and length 71
cm (92nd percentile). While in India, the patient
and his parents had stayed with relatives in an
urban area, and the patient had close contact with
many people, including a relative with pulmonary
tuberculosis who was receiving triple-drug therapy. There were no exposures to animals. The patient had no allergies to medications, and in the
United States he lived with his parents and did
not attend day care. His parents were professionals who had emigrated from India. There was no

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179

The

n e w e ng l a n d j o u r na l

family history of recurrent febrile illnesses, rheumatologic diseases, or immunodeficiency.


On examination, he appeared well he was
playful and breathing comfortably. His weight was
8.2 kg (3rd percentile), temperature 39.3C, pulse
140 beats per minute, respiratory rate 42 breaths
per minute, and oxygen saturation 99% while
breathing ambient air. A well-circumscribed area
of erythema and induration, 1 cm by 2 cm, was
present on the dorsum of the right forearm, and
the incision from the biopsy was clean and dry.
The lungs were clear, and the results of the remainder of the physical examination were normal. Levels of serum electrolytes and glucose were
normal, as were the test results for renal and
liver function; the results of other laboratory tests
are shown in Table 1. Tests of nasal secretions
for antigens of adenovirus, influenza virus types
A and B, parainfluenza virus types 1, 2, and 3,
and respiratory syncytial virus were negative.
Computed tomography (CT) of the chest showed
nodular areas of consolidation throughout both
lungs, some with calcification. The larger opacities were in the upper lobes, up to 2.6 cm by 1.7
cm by 1.9 cm. Some were contiguous with the
hila and extended to the pleural surface. Softtissue fullness in the mediastinum, hila, and left
axilla suggested lymphadenopathy. Acetaminophen
and ibuprofen were administered orally and ceftriaxone intravenously.
On the second hospital day, the temperature
rose to 39.7C. A tuberculin skin test was performed, and an aspirate of gastric secretions
obtained in the early morning was sent for acidfast staining and mycobacterial culture. Isoniazid,
ethambutol, pyrazinamide, and rifampin were begun. Analysis of a urine specimen was normal,
and a culture of the urine specimen, collected in
an external bag, grew few mixed flora. Specimens
of stool were sent for culture of enteric pathogens, presence of Clostridium difficile toxin, and ova
and parasitologic analysis.
During the next 3 days, two additional earlymorning specimens of gastric aspirate were obtained; staining did not reveal acid-fast bacilli
and cultures were pending. On the fourth hospital day, the temperature rose to 40C and the
patient vomited intermittently, occasionally after
episodes of coughing productive of white sputum.
The site of the tuberculin skin test showed no
induration. The next day, the temperature fluctuated between 34.6 and 40.1C. Serum IgG antibodies to cytomegalovirus were present; test
180

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results for EpsteinBarr virus and human immunodeficiency virus antibodies in the serum and
legionella and histoplasma urine antigens were
negative. Other laboratory-test results are shown
in Table 1. Additional specimens of blood were
sent for culture; results of other tests were pending. A review of the slides from the skin biopsy
that had been performed earlier revealed scattered nuclear debris and rare structures suggestive of fungal hyphae; in deeper sections stained
for organisms, these structures were no longer
visible. Ceftriaxone was stopped and meropenem
and liposomal amphotericin were administered
intravenously.
On the sixth hospital day, emesis was tinged
with blood, and a sample of stool was guaiacpositive. The respiratory rate transiently increased
to 66 to 75 breaths per minute, with oxygen saturations between 98 and 100%, then returned to
32 to 44 breaths per minute. The temperature
ranged from 33.9 to 39.6C. Additional chest radiography continued to show bilateral pulmonary
infiltrates. A diagnostic procedure was performed
on the seventh hospital day.

Differ en t i a l Di agnosis
Dr. Jason B. Harris: May we review the radiologic
studies?
Dr. Sjirk J. Westra: CT of the chest, performed
on admission without the administration of contrast material, showed several ill-defined nodules in the posterior lung zones, several of which
contained calcifications; the nodules blended with
the pulmonary hila (Fig. 1A), and some extended
to the pleura. One week later, CT of the chest
performed with the administration of intravenous
contrast material showed fullness of the soft tissues in the mediastinum, which could be explained
by the normal thymus, and mild prominence of
the hilar lymph nodes. The tracheobronchial tree
was normally patent. Large nodules were present, predominantly in the upper lobes of the
lungs, with ill-defined and spiculated margins,
which was probably indicative of inflammation;
the larger nodules were calcified (Fig. 1B). A chest
radiograph taken 5 days later (Fig. 1C) showed
ill-defined nodular infiltrates, predominantly in
the middle- and upper-lung zones, and ill-defined
hilar markings.
The differential diagnosis of bilateral nodular
pulmonary consolidation with calcifications includes granulomatous infection, particularly tu-

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berculosis. However, calcification does not occur


in primary tuberculosis, and postprimary tuberculosis would be unusual in this young child.
Chronic fungal infections frequently calcify,
whereas bacterial and pneumocystic infections
are not usually associated with calcification.
Given the clinical presentation and the appearance of these nodules, a calcifying neoplastic
process, such as inflammatory myofibroblastic
tumor (inflammatory pseudotumor) or a metastatic malignant tumor, was believed to be less
likely than an infection.
Dr. Harris: I participated in the care of this
patient and am aware of the diagnosis. Fever and
a cough developed in this infant during travel in
India, and they recurred despite antibiotic therapy. On admission, his weight gain had slowed.
Imaging studies showed a chronic multinodular
pneumonia with calcification. Our differential
diagnosis included infectious and noninfectious
conditions, and we considered the possibility
that his condition might be a manifestation of
primary immunodeficiency.

Infection with Mycobacterium tuberculosis

This patients young age and close contact with


an adult with pulmonary tuberculosis suggested
a diagnosis of pulmonary tuberculosis, the most
common cause of chronic pneumonia in the world,
C
with approximately 2 million cases per year in
1
India. Infants younger than 1 year of age who
are infected with Mycobacterium tuberculosis are at
extremely high risk for the development of active
disease, estimated to approach 40% in the first
2 years of life as compared with a 5 to 10% cumulative lifetime risk of disease in immunocompetent adults.2 Does this patients clinical presentation support the diagnosis of pulmonary
tuberculosis?
First, is the incubation period consistent with
tuberculosis? This childs symptoms developed
1 month after arriving in India. Infants, unlike
older children or adults, often present with symptomatic primary tuberculosis 3 to 8 weeks after
exposure, and disseminated disease, such as milFigure 1. CT of the Chest.
iary or meningeal tuberculosis, may develop 2 to
An axial CT study of the lungs shows ill-defined nodular pul3
6 months after exposure. Are the other clinical
monary consolidations in the posterior zones (Panel A, archaracteristics of the patients illness consistent
rows).
nodule is partially calcified.
A coronal
RETAKE
1st
AUTHOR Kradin
ICMThe right-sided
with tuberculosis? Although infants are more
2ndin
reformatted
image of
the CT scan shows three nodules
REG F FIGURE
1a-c
3rd
the CASE
upper lung
zones, with calcifications on the right (Panel
likely than adults to present with extrapulmoTITLE
Revised
B). AEMail
chest radiograph showsLine
ill-defined
4-Cnodular opacities,
nary disease, the majority of infants diagnosed
SIZElung
Enon
predominantly
in the
right upper
right middle
ARTIST:
mst
H/T andH/T
with tuberculosis in the United States do in fact
FILL with ill-defined hilar vascular
Combo markings16p6
zones,
(Panel C).
4
cough and fever, as
have isolated pulmonary disease. They typically present with nonproductive
AUTHOR, PLEASE NOTE:
Figure has been redrawn and type has been reset.
Please check carefully.
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181

The

n e w e ng l a n d j o u r na l

present with nonproductive cough and fever, as


this patient did. The erythematous cutaneous
nodule at the site of an intravenous catheter could
be a cutaneous manifestation of tuberculosis, although this would be unusual. However, the
nodule might have resulted from an unrelated
infection, and it appeared to be resolving at the
time of admission. A transient response to amikacin may also be seen in M. tuberculosis infection.
Are the radiographic findings consistent with tu
berculosis? Parenchymal lung disease and mediastinal lymphadenopathy are characteristic of pul
monary tuberculosis in infants. Often there is a
primary complex, consisting of a parenchymal lesion with associated lymphadenitis. Although miliary involvement can occur in congenital tuberculosis, the presence of multiple bilateral pulmonary
nodules, some with calcification, suggesting multi
focal granulomatous inflammation, is atypical.
Finally, what can we learn from the diagnostic studies that were obtained in the first few
days of the patients hospitalization? Acid-fast
bacilli stains of early-morning gastric aspirates
are often negative in children with pulmonary
tuberculosis and have little negative predictive
value; however, cultures will be positive in up to
70% of infants with pulmonary tuberculosis.4
This patient also had a negative response to a
purified-protein-derivative (PPD) skin test for tuberculosis. Although the majority of infants with
disseminated tuberculosis initially have a negative response to this test, 80 to 90% of immunocompetent infants with isolated pulmonary tuberculosis test positive.4,5 Although not definitive,
the negative result on the PPD skin test suggests
that this patient either did not have tuberculosis
or was immunocompromised. Although we were
concerned enough to treat this patient empirically for possible tuberculosis, we considered other
infectious and noninfectious causes of his illness.
Other Causes of Chronic Multinodular
Pneumonia

Histoplasmosis is endemic in India and in the


United States and can mimic tuberculosis. It can
manifest as a primary pulmonary infection, though
infants are predisposed to progressive reticuloendothelial infection characterized by fever, failure
to thrive, and hepatosplenomegaly. In this case,
a urine antigen test was negative. Blastomyces
and cryptococcus are also found in India and can
cause chronic pneumonia and cutaneous mani182

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m e dic i n e

festations, including isolated skin nodules and


ulcers. However, these infections rarely result in
calcified lung lesions. Aspergillus species are an
important cause of nodular pneumonia in immunocompromised hosts, particularly patients
with hematologic malignancies, neutropenia, or
phagocyte disorders, and chronic infections may
calcify. Thus, chronic pulmonary aspergillosis
due to an underlying immunodeficiency was a
consideration, despite the fact that this child had
been healthy for the first 10 months of life.
Nontuberculous mycobacteria need to be considered, especially in view of the negative finding
on the PPD skin test and the partial clinical response to amikacin, which is active against nontuberculous mycobacteria. However, pulmonary
infection of this magnitude with nontuberculous
mycobacteria is rare in a healthy host, and symptoms recurred on use of clarithromycin, which is
highly active against most nontuberculous mycobacterial infections. Burkholderia pseudomallei, the
causative agent of melioidosis, is endemic in India
and can manifest as a chronic, multinodular
pneumonia. Skin manifestations, including ulcers
and abscesses, can occur in isolation or as part of
disseminated disease; thus, melioidosis was a
possible diagnosis in this case. Rhodococcus equi is
an increasingly recognized cause of chronic nodular pneumonia in immunocompromised patients; however, infection with R. equi is typically
associated with exposures to animals or soil,
neither of which was present in this case. Nocardia species can cause chronic lung infections,
including multinodular pneumonia, particularly
in immunocompromised hosts. Paragonimus, a
lung fluke that is endemic in India, can present
as chronic pneumonia with multiple calcified
nodules; however, most patients have peripheral
blood eosinophilia and a history of shellfish exposure, neither of which applied in this case.
Sarcoidosis is a chronic pulmonary granulomatous disease; however, the infantile form, Blau
syndrome, does not typically involve the lungs.
Inflammatory myofibroblastic tumor (also known
as inflammatory pseudotumor or plasma-cell
granuloma), the most common primary lung tumor in children, is often associated with calcification.6 However, most of these tumors are solitary lung lesions and are not associated with
fever. Metastatic Wilms tumor or neuroblastoma
can occur at this age, but there is no evidence of
a primary tumor in the abdomen.

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Chronic Multinodular Pneumonia as a


Manifestation of Primary Immunodeficiency

An early concern was that the patient had a primary immunodeficiency. Primary immunodeficiency disorders are typically suspected in the
presence of repeated infections, opportunistic
infections, failure to thrive, a positive family history for such a disorder, hematologic abnormalities, abnormal responses to common infections,
or characteristic features of a syndrome associated with immunodeficiency, such as DiGeorges
syndrome, which is distinguished by cleft palate,
endocrine abnormalities, and congenital heart defects. Because many immunodeficiency syndromes can present after 6 months of age, the
fact that this child had thrived in early infancy
does not exclude such a diagnosis. Although we
had not documented the presence of an opportunistic infection, the finding of multiple calcified
pulmonary nodules suggested that a chronic
granulomatous process preceded the visit to India and the development of symptoms. This
could represent an abnormal response to infection a characteristic feature of chronic granulomatous disease.
Chronic granulomatous disease, which is due
to a primary defect of the phagocytic NADPH
oxidase pathway, is one of the most common
serious primary immunodeficiency syndromes,
with an incidence of at least 1 in 200,000 births

in the United States.7 The clinical manifestations


are listed in Table 2. Pulmonary infection occurs
in more than 80% of cases, particularly in a form
of calcifying multinodular pneumonia known as
encapsulating pneumonia.7,8 Another common
clinical manifestation is the formation of relatively painless subcutaneous nodules, known as
cold abscesses, which are a classic manifestation
of phagocytic dysfunction. This patients lung
and skin lesions are thus highly characteristic of
chronic granulomatous disease.
The diagnosis of chronic granulomatous disease is often suggested by a microbiologic diagnosis, since the majority of infections in this
disease are due to five catalase-producing microorganisms: Staphylococcus aureus, B. cepacia, Serratia
marcescens, nocardia species, and aspergillus species. Aspergillus is the predominant causative
agent of pulmonary infections, accounting for more
than 40% of cases in which a causative organism
is identified.7 Aspergillus and B. cepacia account
for many of the deaths in patients with chronic
granulomatous disease.7
During the course of our patients treatment
at this hospital, additional information was obtained that increased our concern for chronic
granulomatous disease. Although there was no
family history of immunodeficiency, we learned
that the patients parents were closely related.
Consanguinity greatly increases the likelihood of

Table 2. Commonly Reported Clinical Manifestations of Chronic Granulomatous Disease in the 368 Patients in the U.S.
National Registry.*
Clinical Syndrome

Proportion of
Patients (%)

Pneumonia

79

Abscesses (any)

68

Common Microbiologic Causes in Order of Prevalence


Aspergillus species, staphylococcus species, Burkholderia
cepacia, nocardia species

Subcutaneous

42

Staphylococcus species, serratia species

Liver

27

Staphylococcus species

Lung

16

Aspergillus species

Perirectal

15

None predominates

Lymphadenitis

53

Staphylococcus species

Osteomyelitis

25

Serratia species, aspergillus species

Bacteremia/fungemia

18

Salmonella species, B. cepacia, candida species

Colitis and enteritis syndromes

18

Gastric-outlet obstruction

15

Urinary-outlet obstruction

10

* Reported in 10% or more of cases. Adapted from Winkelstein et al.7


Organisms listed have been identified in more than 10% of cases for each syndrome listed.

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183

The

n e w e ng l a n d j o u r na l

an autosomal recessive disorder. In addition, the


skin biopsy was interpreted as showing a possible
fungal hypha, which heightened our suspicion that
the patient had chronic granulomatous disease.
Other causes of primary immunodeficiency are
much less likely. Cystic fibrosis and ciliary defects
are associated with chronic sinopulmonary disease,
but they are usually associated with bronchiectasis.
T-cell and B-cell immunodeficiencies can present
with pneumonia, but in this case the normal immunoglobulin levels, the lack of lymphopenia, and
the lack of prior recurrent infections or chronic
diarrhea argue against these immunodeficiencies. Other phagocytic disorders include deficiencies in the interferon-interleukin-12 receptor
signaling pathway.9 Like chronic granulomatous
disease, these disorders are associated with a
remarkably specific microbiology typically
mycobacterial infections or nontyphoid salmonellosis. However, these disorders are much less
common than chronic granulomatous disease.

of

m e dic i n e

Diagnostic Testing

To evaluate for chronic granulomatous disease,


on the fourth hospital day we sent peripheralblood leukocytes from this patient to another
laboratory for an oxidative burst assay. While
this result was pending, we obtained a specimen
from the involved lung tissue for histopathology
and culture, which we considered essential to establishing a diagnosis.

Dr . Ja son B . H a r r iss Di agnosis


Infectious pneumonia, probably due to aspergillus
species and probably complicating chronic granulomatous disease.

Pathol o gic a l Discussion


Dr. Richard L. Kradin: Pathological examination of
a video-assisted thoracoscopic biopsy specimen
of the right upper lobe of the lung revealed necrotizing granulomas, primarily centered on small
airways (Fig. 2A), with extensive necrosis and
dystrophic calcifications (Fig. 2B). Special stains
were negative for mycobacteria, but Gomoris methenamine silver staining (Fig. 2C) revealed fragmented, varicose, septate hyphae with rare orthogonal pyriform conidia in areas of necrosis. The
presence of fragmented varicose hyphae with
small, lateral, pyriform conidiophores and conid184

Figure 2. Lung-Biopsy Specimen.


A view of the biopsy specimen of the right upper lung
lobe at low magnification revealed several necrotizing
RETAKEof ne1st
AUTHOR
Kradin (Panel A). A focus
ICM
bronchocentric
granulomas
REGcontains
F FIGURE
2a-c
crosis
dystrophic
calcification (Panel B). At2nd
3rd
CASEmagnification
TITLE
higher
(Panel C), a granulomaRevised
with
EMail
4-C
multinucleated giant cells isLine
seen. Staining
with GoSIZE
Enon
ARTIST: mstsilver (Panel
H/T
moris
methenamine
C,H/T
inset, lower left)
16p6
FILL
Combo
reveals a fragmented septate fungal hypha with a conAUTHOR,
stricted right-angle
branchPLEASE
point.NOTE:
The fungal hypha is
Figure has been redrawn and type has been reset.
stained with antibody
specific
for
aspergillus species
Please check carefully.
(Panel C, inset, lower right).
JOB:

35902

ISSUE:

7-10-08

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A Unstimulated

Cell Number

Unrelated Healthy Control

Patient

250

250

200

200

150

150

100

100

50

50

0
100

101

102

103

104

0
100

101

Fluorescence Intensity

102

103

104

Fluorescence Intensity

B PMA-Stimulated

Cell Number

Unrelated Healthy Control

Patient

250

250

200

200

150

150

100

100

50

50

0
100

101

102

103

104

0
100

Fluorescence Intensity

101

102

103

104

Fluorescence Intensity

Figure 3. Dihydrorhodamine-123 Fluorescence Assay of Peripheral-Blood Neutrophils from the Patient and an Unrelated Healthy Control.
1st
RETAKE
AUTHOR: Kradin
ICM
In this fluorescence assay of peripheral-blood
neutrophils
from the patient and an 2nd
unrelated healthy control, neutro3 of 4
REG F FIGURE:
3rd
phils are stimulated with phorbol myristate
acetate
(PMA)
in
the
presence
of
dihydrorhodamine-123,
and flow cyCASE
Revised
tometry is used to measure the oxidative
burst mediated by
NADPH
quantifying the fluorescent product,
4-Coxidase by
Line
EMail
SIZE
ARTIST:
ts healthy
rhodamine. Shown are baseline histograms
from the
and the patient
H/T
H/Tcontrol
33p9 before stimulation with PMA
Enon
(Panel A). After PMA stimulation (Panel B), the histogram Combo
from the control shows a unimodal shift of fluorescence
AUTHOR,
PLEASE
NOTE:
far to the right, whereas the patient has a broad-based
shift
in fluorescence
that is only approximately 1/10 the size
Figure
has been redrawn
and type of
hasautosomal
been reset. recessive chronic granulomatous
of the shift observed in the control. This
abnormality
is suggestive
Please check carefully.
disease.
JOB: 35902

ia in tissue are typical of aspergillus of the flavipesterreus group.10 A hyphal form was highlighted by immunohistochemical staining for
aspergillus species. Cultures of the specimen
showed no growth of fungi or bacteria, but a
culture of the skin-biopsy specimen that had
been obtained before admission grew Aspergillus
terreus. Patients with chronic granulomatous disease are most commonly infected with A. fumigatus or A. nidulans.11 A. terreus is a ubiquitous environmental fungus, which is emerging as an
important pathogen in pulmonary infections in
immunocompromised hosts.12,13
The host response to aspergillus in this case
mimics that of a mycobacterial or fungal yeast infection. Whereas invasive infections due to asper-

ISSUE: 07-10-08

gillus species are well recognized in chronic


granulomatous disease, well-defined necrotizing
granulomatous inflammation is infrequent. As
there was no evidence of angioinvasion in the
sampled lung tissue, the infection is best classified as invasive chronic necrotizing aspergillosis, which is distinguished specifically by the
absence of vascular invasion.
Dr. Ian C. Michelow: The dihydrorhodamine assay, a quantitative measure of NADPH oxidase
function during the respiratory burst of phagocytic cells, is the diagnostic test for chronic
granulomatous disease. Chronic granulomatous
disease is caused by mutations in genes that
encode for one or more of the six components of
the NADPH oxidase complex, an enzyme that is

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The New England Journal of Medicine


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185

The

n e w e ng l a n d j o u r na l

of

m e dic i n e

present in phagocytes such as neutrophils, monocytes, and macrophages and is critical to the
Plasma membrane
Secretory vesicle
production of the reactive oxygen species that
or specific granule
help eradicate organisms that have been subject
to phagocytosis. In our patient, the assay (Fig. 3)
gp91phox
showed a broad peak of fluorescence that was
lower than that of normal neutrophils, a pattern
typically associated with autosomal recessive
Phagosome
p22phox
variants of chronic granulomatous disease.14 AsRac2
says from patients with X-linked chronic granulomatous disease typically demonstrate a narrow
phox
p67
Cytosol
peak, with activation in response to stimulation
p40phox
virtually absent. Test results for the parents were
NADPH oxidase
complex
normal; since a carrier of the X-linked form would
p47phox
be expected to have a dual population of neutrophils, some showing normal activation and others with decreased activation, this finding sugB
gests a diagnosis of autosomal recessive chronic
Phagosome
granulomatous disease.
We then proceeded to genetic testing. The
30
36
?
?
majority of cases of chronic granulomatous disease are due to mutations in the gene gp91phox,
which causes the X-linked disorder (accounting
10
for approximately 70% of cases). Autosomal re50
92
110
Cytosol
cessive cases are caused by abnormalities in the
genes p47phox (approximately 20%), p22phox (apNH2
proximately 5%), and p67phox (approximately 5%).
195
151
160
COOH
Rarely, abnormalities in Rac2, a small guano
129
p47phox binding site
sine triphosphatase, or GTPase, can cause a
chronic granulomatous diseaselike phenotype.
phox
In this patient, sequencing of the relevant genes
Figure 4. The NADPH Oxidase Complex and a Proposed Model for p22
identified a novel missense mutation in the
Topology.
COLOR FIGURE
p22phox gene, in which lysine was substituted for
When a phagocyte ingests a pathogen, secretory vesicles
or specific granules fuse with the phagosome (Panel A). This activates
oxidase
Rev4 the NADPH06/16/08
glutamic acid at amino acid 129 of exon 6. The
phox
complex, which has six components, including
(91-kD
glycoprotein,
Authorgp91 Dr.
Kradin
interactions among the six NADPH oxidase comalso known as cytochrome b- subunit, or heavy chain) and p22phox (cytoFig #
4
ponents are shown in Figure 4A. Figure 4B shows
chrome b- subunit, or light chain), which are both membrane-bound. The
Title
phox
a proposed model for p22phox topology.15 An alterother four components of the complex are located in the cytosol: p47
ME
phox
phox
native model exists,17,18 but there is consensus
(neutrophil cytosolic factor 1), p67 (neutrophil cytosolic factor 2), p40
Harris
DE
(neutrophil cytosolic factor 4), and the small GTPase Rac2. The activated
about the location of the target for p47phox bindDaniel
Mullerthe
Artist
complex assembles on the phagosome membrane.
Once
activated,
ing as shown in the figure. The patients mutaPLEASE
NADPH oxidase transfers electrons from NADPHAUTHOR
to molecular
ONOTE:
2 , resultFigure has been redrawn and type has been reset tion at amino acid 129 appears to affect the
ing in the formation of superoxide anions in the phagosome.
enzyme
Please checkThe
carefully
ability of p22phox and gp91phox to form the flavosuperoxide dismutase catalyzes the formation of H2O2, the fate of which
Issue date 07-10-2008
cytochrome b heterodimer (Dinauer M: personal
depends on the presence of myeloperoxidase, an enzyme that converts
H2O2 to hypochlorous acid and hydroxyl radicals, or catalase, an enzyme
communication), which presumably causes lack
that converts H2O2 to H2O and O2. The reactive oxygen species are reof expression of flavocytochrome b (gp91phox and
sponsible for killing pathogens. Normal oxidative activity of the NADPH
p22phox complex) in neutrophils, as in most other
complex requires fully functional individual components. A proposed model
patients with a documented p22phox mutation.
for p22phox topology is shown in Panel B. The proline-rich domain from amino
The treatment of documented or suspected
acids 151 to 160 (each number refers to the corresponding amino acid) is a
well-characterized target for p47phox binding. The patients mutation at amiinvasive infections in a patient such as this with
no acid 129 (arrow) presumably causes lack of expression of the flavocytochronic granulomatous disease is the same as for
chrome b (the gp91phox and p22phox complex) in neutrophils. NH2 denotes
other immunocompromised hosts. Long-term
the amino terminal, and COOH the carboxy terminal. Adapted from Dahan
15
16
treatment with interferon- has been shown to
et al. and Roos et al.
reduce the frequency of opportunistic infections,
A

186

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case records of the massachusetts gener al hospital

as has prophylaxis with trimethoprimsulfa


methoxazole and itraconazole. Currently, the
only widely accepted definitive treatment is bone
marrow transplantation.19,20
Dr. Harris: Unfortunately the patients condition
continued to deteriorate, and a seeming Pandoras
box of microbiology was opened. A blood culture
obtained on hospital day 4 grew Candida parapsilosis at 72 hours, the skin biopsy obtained before
admission grew A. terreus after 7 days, and blood
cultures obtained on hospital days 11 through
17 were persistently positive for B. cepacia, despite
the organisms susceptibility to meropenem, which
the patient had been taking since hospital day 4.
In addition to antimicrobial chemotherapy, treat-

ment included interferon- and eventually a granulocyte transfusion, which was performed in the
setting of sepsis and multiorgan failure. The patient died on hospital day 17, and permission for
an autopsy was not obtained. The results of the
genetic tests were obtained after the patient died.

A nat omic a l Di agnosis


Necrotizing granulomatous pneumonitis due to
A. terreus, complicating chronic granulomatous
disease.
No potential conflict of interest relevant to this article was reported.
We thank Mary Dinauer, M.D., Ph.D., for her insightful comments.

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187